Redo Fundoplication Research Articles

Outcomes of redo surgery for failed laparoscopic fundoplication

The number of operations for laparoscopic antireflux surgery in Japan is much less than that in Western countries. This study’s aim was to evaluate outcome measures for redo antireflux surgery (redo-ARS) in Japanese patients. Subjects consisted of 11 patients (2.3 %) who required redo-ARS, from an original group of 474 patients who had a primary ARS between December 1994 and January 2015. The mean age of the subjects was 57.7 years, and six of 11 patients were women (55 %). Clinical data were collected in a prospective manner, and were then reviewed retrospectively. The most common cause of failed primary ARS was dislocation of the wrap (6/11 or 54 %). Of the 11 patients, 10 (91 %) were approached laparoscopically, with one requiring conversion to open surgery. Eight (73 %) underwent redo fundoplication, and the others had hiatal hernia repair alone. Mean operation time and blood loss were 202 min and 56 mL, respectively. A perioperative gastric wall injury occurred in three patients. The postoperative course was uneventful in majority patients. Three (27 %) were required to take proton pump inhibitor (PPI), and two (18 %) had a recurrence of hiatal hernia. A postoperative questionnaire was answered by seven of 11 (63 %), and these all reported a high level of satisfaction with their surgery. Redo-ARS can be performed safely under laparoscopy. There was no recurrence rate in almost 80 %, and more than 70 % of patients were withdrawn from PPI treatment postoperatively.

Review of the Experience with Re-Operation After Laparoscopic Nissen Fundoplication.

The risk of redo fundoplication has been demonstrated to be significantly higher in patients of younger age, those with ongoing retching, and those who underwent more extensive dissection of the esophageal hiatus at the initial operation. The purpose of this study was to review the management and outcomes of patients who required one or more re-operations for recurrence after laparoscopic fundoplication. After obtaining Institutional Review Board approval, we performed a retrospective review of all patients who underwent laparoscopic Nissen fundoplication from 2000 to 2013 and subsequently required a redo operation for recurrence. Patient demographics, neurologic impairment, interval time between re-operations, operative approach, use of mesh, and length of follow-up were analyzed. Two-tailed independent Student's t test was used to compare continuous variables, and two-tailed chi-squared test with Yates's correction (Fisher's exact test where appropriate) was used for discrete variables. Eighty-two patients (10.3% of the sample) required re-operation during the study period. The mean age at initial surgery was 1.8 ± 3.6 years. Fifteen patients (18.3%) required more than one re-operation. Of the 102 re-operations performed, 68 were successfully managed laparoscopically, 3 required conversion to an open procedure, and 31 were performed open from the outset. Of those patients requiring more than one re-operation, there was no difference in age, weight, use of mesh, or time to subsequent re-operations compared with patients that only required one redo fundoplication. The incidence of patients requiring another operation after a redo operation after an initial laparoscopic fundoplication is 18%. Patient demographics and time to re-operation have not been found to be predictive of which patient will require multiple re-operations for recurrence. However, younger patients and those with a shorter time to re-operation may increase the likelihood of failure.

Outcomes of fundoplication for paediatric gastroesophageal reflux disease

Outcomes of fundoplication in children. In this monocentric retrospective study, chart review was performed on children who underwent fundoplication between 2006 and 2013. Outcomes were defined as the need for redo fundoplication and recommencement of anti-reflux medication (ARM) at 6-month follow-up. 119 patients underwent fundoplication with a mean age of 4.76 years and 55.5% of these were male. At 6-month follow-up, 21 (17.6%) required redo fundoplication and 64 (53.8%) were recommenced on ARM. Post-operative complications occurred in 50 (42.2%) of children; 30% of those with complications had surgery at less than 1 year of age, and 36% had an associated comorbid condition. Neither being under the age of one nor associated comorbidity was significantly associated with a poor outcome. Concurrent gastrostomy was associated with a higher risk of being back on ARM at 6-month follow-up (p = 0.003). Neither gastrointestinal or respiratory symptoms pre-surgery nor abnormal pre-operative investigations including pH monitoring and endoscopy were predictive of poor outcome post-fundoplication. Although fundoplication has a role in the treatment of severe GORD in children, the majority of children in this study needed to restart their anti-reflux medications within 6 months of surgery.

Combined Laparoscopic and Robot-Assisted Gastroesophageal Dissociation for Recurrent Gastroesophageal Reflux Disease

Abstract Introduction: Laparoscopic Nissen fundoplication has become a very important tool for controlling severe gastroesophageal reflux disease (GERD) in the pediatric population. However, some patients, especially those who are neurologically impaired, may develop recurrent GERD that is refractory to continued medical management. If the fundoplication loosens or fails, recent literature has shown promising long-term results from gastroesophageal dissociation (GED) compared with redo fundoplication. The video demonstrates the laparoscopic operation and the use of a robotics technique to ensure correct placement of sutures. Background: A retrospective review was performed on pediatric robot-assisted GED operations between October 2013 and July 2014 in our practice. Three robot-assisted GED were performed on pediatric patients, 3 to 11 years old. All patients had previous Nissen fundoplications with subsequent development of recurrent reflux symptoms and/or recurrent pneumonias. Minimally Invasive Method:...

Endoscopic clipping of the Z-line (CMZL) helps recognize anatomical failures after Nissen fundoplication: technical report of a new method.

IntroductionNearly 15% of patients after laparoscopic antireflux surgery experience recurrence of symptoms or develop new gastrointestinal symptoms. Some of them require redo procedures. It can be demanding to reveal anatomical failure after previous fundoplication.AimTo present a method which assists in recognition of anatomical failures after Nissen fundoplication.Material and methodsFive patients with previous laparoscopic Nissen fundoplication and severe gastrointestinal symptoms were included in this study. During the esophagogastroduodenoscopy (EGDS) two radiopaque metal clips were placed to mark the Z-line (“clips-marked Z-line” – CMZL). It was done to achieve precise visualization of the gastroesophageal junction area in the video contrast investigation. Distinctions between conclusions after the EGDS, ordinary video contrast investigation, video contrast investigation with CMZL and intraoperative findings were analyzed.ResultsAll patients underwent laparoscopic refundoplication with good postoperative results. There were 4 cases misdiagnosed by contrast investigation without clips and four cases misdiagnosed by EGDS. Endoscopic clipping helped to recognize correctly all anatomical failures.ConclusionsApplying CMZL as a routine investigation before redo fundoplication can reduce frequency of misdiagnosis and help to perform redo fundoplication in appropriate patients, but it requires further studies on larger cohorts of patients.

Dysphagia after laparoscopic total fundoplication: anterior or posterior gastric wall fundoplication?

The occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease. Compare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF). Analysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF - n = 160) and Group 2 (Nissen LTF - n = 129). The overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (= 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF. The overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia.

Fever after redo Nissen fundoplication with hiatal hernia repair

BackgroundFevers often arise after redo fundoplication with hiatal hernia repair. We reviewed our experience to evaluate the yield of a fever work-up in this population. MethodsWe performed a retrospective review of children undergoing redo Nissen fundoplication with hiatal hernia repair between December 2001 and September 2012. Temperatures and fever evaluations of those children receiving a mesh repair were compared with those without mesh. A fever defined as temperature ≥38.4°C. ResultsFifty one children received 46 laparoscopic, 4 open, and 1 laparoscopic converted to open procedures. Biosynthetic mesh was used in 25 children whereas 26 underwent repair without mesh. A fever occurred in 56% of those repaired with mesh compared with 23.1% without mesh (P = 0.02). A fever evaluation was conducted in 32% of those with mesh compared with 11.5% without mesh (P = 0.52). A urinary tract infection was identified in one child after mesh use and an infection was identified in two children without mesh, one pneumonia and one wound infection (P = 1). In those repaired with mesh, there was no significant difference in maximum temperature. ConclusionsFever is common after redo Nissen fundoplication with hiatal hernia repair and occurs more frequently, and with higher temperatures in those with mesh. Fever work-up in these patients is unlikely to yield an infectious source and is attributed to the extensive dissection during the redo procedure.

Su1801 A Large, Single-Surgeon Experience With Laparoscopic Redo Fundoplication: Operative Technique and Long-Term Outcomes

Su1801 A Large, Single-Surgeon Experience With Laparoscopic Redo Fundoplication: Operative Technique and Long-Term Outcomes

Unilateral versus bilateral wrap crural fixation in laparoscopic Nissen fundoplication for children.

Introduction:Gastroesophageal reflux (GERD) is common in neurologically impaired (NI) children. Fundoplication and gastrostomy have previously been indicated in NI children with GERD who have not responded to medical treatment. The most common reason for fundoplication failure is intrathoracic migration of the wrap.Objective:The aim of the study is to measure the effect of wrap fixation on the final outcome of laparoscopic Nissen fundoplication in NI children.Patients and Methods:A retrospective file review was conducted for all NI children who underwent laparoscopic Nissen fundoplication in 2 tertiary pediatric surgery centers in the United Arab Emirates from February 15, 2006 to February 15, 2013. Redo fundoplication patients were excluded from the study. Patients were divided into 2 groups: group 1 in which the fundoplication wrap was fixed to the right crus only, and group 2 in which the wrap was fixed to the right and left crus simultaneously.Results:The study population included 68 patients; there were 47 male and 21 female children. Mean age at time of surgery was 8.2 years. Recurrent GERD at 1 year postoperatively was 26% versus 7% in group 1 and group 2, respectively, by upper contrast study. Redo surgery was required in 21% versus 3% in group 1 and group 2, respectively.Conclusions:Bilateral fixation of the wrap to diaphragmatic crura significantly reduced recurrent GERD, in laparoscopic Nissen fundoplication for neurologically impaired children, with no increased risk of morbidities. Future prospective studies should be conducted with larger patient populations and longer follow-up periods.

Long-Term Patient Outcomes After Laparoscopic Anti-Reflux Procedures

BackgroundLaparoscopic anti-reflux surgery with or without large hiatal hernia has been shown to have good short-term outcomes. However, limited data are available on long-term outcomes of greater than 5 years. The aim of this study is to review functional and symptomatic outcomes of anit-reflux surgery in a large tertiary referral medical center. MethodsTwo hundred ninety-seven patients who underwent anti-reflux surgery at the University of Nebraska Medical Center between 2002 and 2013 were included in this study. Patient data including pre- and post-operative studies and symptom questionnaires were prospectively collected and the database was used to analyze postoperative outcomes. ResultsA total of 297 Nissen fundoplications, 35 redo fundoplications and 22 Toupet procedures were performed. Mean BMI was 30.0 ± 6.2. The median follow-up was 70 (6–135) months. There were three reoperations (0.9 %) for recurrent symptoms. Mesh was used in 210 cases where hiatal hernia was larger than 2 cm. Median preoperative DeMeester score was 50.8 ± 46. There was a statistically significant improvement in composite heartburn score (83 % (CI 78.2, 87.7); p < 0.05), regurgitation (81.1 % (CI 76.1, 86.1); p < 0.05), and belching (63 % (CI 56.7, 69.3); p < 0.05). Atypical presentation such as pulmonary (e.g., aspiration (25.8 % (CI 20, 31.6), wheezing (20.3 % (CI 15, 25.6); p < 0.05), and throat symptoms (e.g., laryngitis 28 % (CI 22.1, 33.9); p < 0.05) also improved. Available radiographic studies for patients more than 3 years follow-up show an overall recurrence of 33.9 % (47.8 % in hiatal hernia > 5 cm repaired with mesh). Of those with recurrence, over 84 % were asymptomatic at follow-up. ConclusionsThis study shows that patients had excellent symptom control and low rates of complications and reoperations in long-term follow-up. We found that typical gastro intestinal symptoms responded better compared with atypical symptoms in spite of clear evidence of reflux on preoperative studies. Hiatal hernia was very commonly seen in our patient population and long-term radiographic follow-up suggest that asymptomatic recurrence may be high but rarely requires any surgical intervention. Anti-reflux surgery with correction of hiatal hernia if present is safe and effective in long-term follow-up.

Reoperative Intervention in Patients with Mesh at the Hiatus is Associated with High Incidence of Esophageal Resection—A Single-Center Experience

BackgroundMesh hiatoplasty is a widely debated topic among foregut surgeons. While short-term outcomes tout decreased recurrence rates, an increase in mesh-related complications has been reported. The aim of this study is to present a single-center experience with reoperative intervention in patients with previous mesh at the hiatus. MethodsAfter institutional review board approval, a prospectively maintained database was retrospectively queried to identify patients who underwent reoperative intervention between 2003 and spring of 2013 and had mesh placed at a previous hiatal hernia procedure. Patient charts were reviewed and data variables collected. ResultsTwenty-six patients (mean age of 56.7 ± 18.3; 19 females) who underwent 27 procedures met the inclusion criteria. Synthetic mesh was placed in 15 (56 %) procedures, while the remaining 12 had biologic mesh. The mean interval between reoperative intervention and previous surgery was 33 months. Dysphagia (56 %) was the most common presentation, while three patients had mesh erosion. Recurrent hiatus hernia (2 to 7 cm) was noted in 19 (70 %) patients. Eight patients (30 %) underwent redo fundoplication, six patients (22 %) were converted to Roux-en-Y gastrojejunostomy, two patients (7.4 %) underwent distal esophagectomy with esophagojejunostomy, five patients (19 %) had subtotal esophagectomy with gastric pull-up, and one patient underwent substernal gastric pull-up for esophageal bypass with interval esophagectomy. The mean operative time was 252 ± 71.7 min, and the median blood loss was 150 ml (range, 50–1,650 ml). There was no postoperative mortality. ConclusionReoperative intervention in patients with mesh at the hiatus is associated with a high need for esophageal resection. More than two thirds of the patients also had a recurrent hiatal hernia.

Long-term outcomes of reintervention for failed fundoplication: redo fundoplication versus Roux-en-Y reconstruction

Redo fundoplication (RF) is the mainstay of treatment for failed fundoplication. A subset of patients with failed fundoplication requires Roux-en-Y reconstruction (RNY) for symptom relief. The aim of this study was to compare the long-term subjective outcomes between RF and RNY in patients with failed fundoplication. After Institutional Board Review approval, retrospective review of a prospective database identified 119 RF (mean = 54.1 years, 78 women) and 64 RNY (mean = 54.8 years, 35 women) patients who underwent reoperative surgery between December 2003 and September 2009. Data variables analyzed included demographics, esophageal manometry, 24-h pH study, type of procedure, perioperative findings, complications, pre- and postoperative symptom (heartburn, regurgitation, dysphagia, and chest pain) scores (scale 0-3), and patient satisfaction score (scale 1-10). Patients with grade 2 and 3 scores were considered to have significant symptoms. Patients who underwent RNY had a significantly higher body mass index, higher mean number of risk factors, and higher preoperative severity of heartburn and regurgitation compared to the RF group. Of the 183 patients, long-term (>3 years) follow-up was available for 132 (89 RF and 43 RNY) patients. Symptom severity significantly improved after both procedures, with the exception of dysphagia in the RNY group. Overall, there was no significant difference in patients' satisfaction between the RF and RNY groups. In subset analysis, patients with morbid obesity, esophageal dysmotility, or ≥4 risk factors have better satisfaction with RNY compared to RF (p = 0.027, 0.031, and 0.045, respectively). RF and RNY have equally good patient satisfaction at 3 years follow-up. RNY may have improved outcomes in patients who are morbid obese, have esophageal dysmotility, or have four or more risk factors.

Two Decades of Experience with Laparoscopic Nissen Fundoplication in Infants and Children: A Critical Evaluation of Indications, Technique, and Results

Laparoscopic fundoplication for gastroesophageal reflux disease has become a common procedure performed in infants and children over the last 20 years. This report describes a 20-year experience with nearly 2000 consecutive laparoscopic Nissen fundoplications. With Institutional Review Board approval, the data of all patients undergoing fundoplication from 1992 to 2011 were reviewed. Data were kept prospectively from the time of first encounter with each patient. Ages ranged from 5 days to 18 years, and weight ranged from 1.2 to 120 kg. The 2008 fundoplications were performed by or under the direct supervision of a single surgeon. Patients were divided into groups based on age: <6 months, 6-12 months, 1-6 years, and >6 years. Data on indications, surgical demographics, postoperative course including any complications, and long-term follow-up were kept prospectively on each patient. Average operative time dropped dramatically from 109 minutes for the first 30 cases compared with 35 minutes for the last 30. Of the 283 procedures that were redo fundoplications, 85 patients had had previous open surgery, and 198 cases had had previous laparoscopic surgery. Intraoperative and postoperative complication rates were 0.13% and 4.0%, respectively, in the primary group but were 2.2% and 4.2%, respectively, in the redo group. Average time to discharge post-fundoplication for the primary group was 1.1 days. The overall wrap failure rate for primary fundoplications was 4.6% and was highest in the <6-month age group. The failure rate in the redo group was 6.8%. The most common causes of wrap failure were hiatal hernia (46%) and slipped Nissen (34%). This study shows in a large operative experience over 20 years that laparoscopic fundoplication is safe and effective in the pediatric population. Technical considerations are paramount to improved outcomes, and key points include adequate creation of intraabdominal esophagus, limited hiatal dissection, creation of a tension-free and appropriate orientation, and positioning of the wrap. Clinical results are favorable to the traditional open fundoplication but with a significant decrease in morbidity and hospitalization. Laparoscopic Nissen fundoplication should be considered the gold standard for antireflux procedures.

A multicenter study of the incidence and factors associated with redo Nissen fundoplication in children

AimThe objective of this study was to identify the incidence and factors associated with redo Nissen fundoplication in children. MethodsAfter Institutional Review Board approval (5100277), data for children under 18years of age from two children's hospitals with fundoplication performed between January 1994 and December 2010 were reviewed. Children with one fundoplication were compared to those with redos to identify factors associated with redo.Variables were compared using t-tests for continuous and chi-square tests for categorical variables. Logistic regression evaluated for independence. ResultsThere were 823 patients and 54.7% were male. A redo fundoplication was required in 100 (12.2% of cohort); 82 had 1 redo, 14 had 2 redos, and 4 had 3 redos. Follow-up ranged from 0.01 to 16.9years (median: 2.9years).Factors associated with redo were: younger age at first fundoplication, (p=0.002), hiatal dissection (p<0.001), and male gender (p=0.008). Independent predictors of redo were: hiatal dissection at first fundoplication, OR: 8.45 (95% CI: 2.45–29.11), retching, OR: 3.59 (95% CI: 1.56–8.25) and younger age at first fundoplication, OR: 0.98 (95% CI: 0.97–0.98). ConclusionThe incidence of redo fundoplication in children is 12.2%. The risk of redo is significantly increased if patients are younger, have retching, and if the esophageal hiatus is dissected at the first fundoplication.

590 Influence of Ethnicity on the Efficacy and Utilization of Bariatric Surgery in the United States

Background: Increasing use of mesh for hiatus repair during anti-reflux surgery has been reported. Re-operative intervention with previously placed mesh is technically more challenging. The aim of this study is to present a single Center experience with reoperative intervention in patients with previous mesh at hiatus and outcomes in this subset of patients. Methods: After Institutional review board approval prospectively maintained database was retrospectively queried to identify patients who underwent re-operative intervention between 2003 to 2012 and had mesh placed at a previous hiatal hernia procedure. Patient charts were reviewed and variables collected included demographics, indications, operative details (initial and reoperative) and postoperative complications. Results: Twenty-six patients met inclusion criteria and form the cohort for the study. There were 14 females with a mean age of 58.3 + 29.2 years. Synthetic mesh was placed in 15 (58%) patients, while the remaining 11 had bio-prosthetic mesh. Mean duration of re-operative intervention since the last surgery was 22 (1-52) months. Dysphagia (57%) was the most common presentation while 4 patients had mesh erosion. Recurrent hiatus hernia (2 to 7 cm) was noted in 16 (62%) patients. Nine patients (35%) underwent redo fundoplication, 8 (31%) were converted to Roux en Y gastrojejunostomy, 3 (12%) underwent distal esophagectomy with esophago-jejunostomy, 5 (19%) had subtotal esophagectomy with gastric pull-up and one patient underwent substernal gastric pull-up for esophageal bypass with interval esophagectomy. The mean operative time was 250 + 70.1 min, the median blood loss was 150 ml (50-1650 ml). Reoperative intervention was performed with laparoscopic approach in 50% (13/26) of the patients, laparoscopy converted to laparotomy in 12% (3/26) of the patients, laparotomy was performed in 34% (9/26) and thoracotomy was performed in 1 patient. There was no post-operative mortality. Major complications were noted in 6 patients. Mean ICU stay was 6 days and hospital stay was 14 days. Conclusion: Reoperative intervention in patients with mesh at hiatus is associated with a high (.35 %) need for esophageal resection. More than half the patients also had a recurrent hiatal hernia. Caution is advised in liberal use of mesh for hiatoplasty.

589 Reoperative Intervention in Patients With Mesh At Hiatus Is Associated With High Morbidity and High Incidence of Esophageal Resection - Single Center Experience

Background: Increasing use of mesh for hiatus repair during anti-reflux surgery has been reported. Re-operative intervention with previously placed mesh is technically more challenging. The aim of this study is to present a single Center experience with reoperative intervention in patients with previous mesh at hiatus and outcomes in this subset of patients. Methods: After Institutional review board approval prospectively maintained database was retrospectively queried to identify patients who underwent re-operative intervention between 2003 to 2012 and had mesh placed at a previous hiatal hernia procedure. Patient charts were reviewed and variables collected included demographics, indications, operative details (initial and reoperative) and postoperative complications. Results: Twenty-six patients met inclusion criteria and form the cohort for the study. There were 14 females with a mean age of 58.3 + 29.2 years. Synthetic mesh was placed in 15 (58%) patients, while the remaining 11 had bio-prosthetic mesh. Mean duration of re-operative intervention since the last surgery was 22 (1-52) months. Dysphagia (57%) was the most common presentation while 4 patients had mesh erosion. Recurrent hiatus hernia (2 to 7 cm) was noted in 16 (62%) patients. Nine patients (35%) underwent redo fundoplication, 8 (31%) were converted to Roux en Y gastrojejunostomy, 3 (12%) underwent distal esophagectomy with esophago-jejunostomy, 5 (19%) had subtotal esophagectomy with gastric pull-up and one patient underwent substernal gastric pull-up for esophageal bypass with interval esophagectomy. The mean operative time was 250 + 70.1 min, the median blood loss was 150 ml (50-1650 ml). Reoperative intervention was performed with laparoscopic approach in 50% (13/26) of the patients, laparoscopy converted to laparotomy in 12% (3/26) of the patients, laparotomy was performed in 34% (9/26) and thoracotomy was performed in 1 patient. There was no post-operative mortality. Major complications were noted in 6 patients. Mean ICU stay was 6 days and hospital stay was 14 days. Conclusion: Reoperative intervention in patients with mesh at hiatus is associated with a high (.35 %) need for esophageal resection. More than half the patients also had a recurrent hiatal hernia. Caution is advised in liberal use of mesh for hiatoplasty.

Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication

Even skilled surgeons will have complications after antireflux surgery. Fortunately, the mortality is low (<1%) with laparoscopic surgery, immediate postoperative morbidity is uncommon (5%-20%), and conversion to an open operation is <2.5%. Common late postoperative complications include gas-bloat syndrome (up to 85%), dysphagia (10%-50%), diarrhea (18%-33%), and recurrent heartburn (10%-62%). Most of these complications improve during the 3-6 months after surgery. Dietary modifications, pharmacologic therapies, and esophageal dilation may be helpful. Failures after antireflux surgery usually occur within the first 2 years after the initial operation. They fall into 5 patterns: herniation of the fundoplication into the chest, slipped fundoplication, tight fundoplication, paraesophageal hernia, and malposition of the fundoplication. Reoperation rates range from 0%-15% and should be performed by experienced foregut surgeons.

Roux-en-Y reconstruction is superior to redo fundoplication in a subset of patients with failed antireflux surgery

A subset of patients requires reoperative antireflux surgery (Re-ARS) after failed fundoplication. The aim of this study was to determine symptomatic outcomes beyond 1 year following Re-ARS and to assess the relative utility of two different surgical approaches. After Institutional Review Board approval, patients who underwent Re-ARS were identified from a prospective database. Symptom severity was graded on a 0-3 scale. Patients with postoperative symptoms of grade ≥ 2 were considered to have a poor outcome. Patient satisfaction was graded using a 10-point visual analog scale. At least 1 year of follow-up was available for 130 patients. There were 94 redo fundoplications (RF) and 36 Roux-en-Y reconstructions (RNYR). Symptom risk factors (significant preoperative dysphagia, significant preoperative heartburn, esophageal dysmotility, short esophagus, delayed gastric emptying, multiple failed hiatal surgeries, reflux-related respiratory symptoms) were more prevalent in patients who underwent RNYR compared to RF (mean 3.0 vs. 2.2; p = 0.003). Postoperative leaks and major complications occurred in 4.5 % (5/110) versus 0% and 21.6 % versus 33.3 % of the RF and RNYR groups, respectively. Twenty-eight RF patients (29.8 %) and 9 RNYR patients (25.0 %) reported poor outcomes. Among patients with ≥ 4 risk factors, those who underwent RNYR had a lower incidence of poor outcome (7.7 % vs. 55 %, p = 0.018) and higher satisfaction scores (8.4 vs. 5.8, p = 0.001) compared to those who had RF. Overall, 85 % of patients were satisfied or highly satisfied with their results and the average satisfaction score was 8.2. Re-ARS provides good subjective outcomes when measured more than 1 year after surgery. Patients with more complex pathology benefit more from RNYR despite the higher postoperative complication rate. This is especially true for patients with decreased esophageal motility and short esophagus.

PWE-163 Factors predicting extended length of stay following laparoscopic Nissen fundoplication: a move towards day case surgery

IntroductionThere has been a move towards performing laparoscopic gastric fundoplication as a “day-case” procedure. This study aimed to determine which factors influence length of stay (LOS) to better enable patient...

Re-operation for failed gastro-esophageal fundoplication. What results to expect?

The aim of this study is to evaluate short and medium term results of re-operation for failed fundoplication in a retrospective monocentric cohort of 47 patients. Between 1995 and 2011, 595 patients underwent a laparoscopic primary fundoplication (PFP) for gastroesophageal reflux disease (GERD). During the same period, 47 patients required a re-operative fundoplication (RFP). In 11 patients, the original wrap had herniated into the thorax. All these revisions consisted of a complete takedown of the original wrap before constructing a tension-free wrap using a standardized technique. Patients with a follow-up of at least 2 years were matched to patients who had been operated only once to assess satisfaction and quality of life. Short term: All patients were operated by laparoscopy with no conversion. There was no mortality. Two postoperative complications necessitating re-operation were observed (morbidity 4.3%): one complete aphagia and one gastric perforation. Long term: 29 re-operated patients with a follow-up of at least 2 years (mean: 4,5 years) (Group RFP) were compared to a matched group of 29 patients operated only once (Group PFP). These groups were comparable in age, sex ratio, BMI and follow-up. In both groups, all patients were operated by laparoscopy without conversion. Morbidity was 3.5% in the RFP group, none in the PFP group. There was no mortality in either group. The length of stay and operative time were significantly higher in the RFP group (4.6 vs. 2.6 days, p<0.05). Two RFP patients (5%) required re-operation at three and seven months vs. none in the PFP group. The long-term satisfaction was comparable in the two groups (78% vs. 85%, p=NS). Quality of life assessed by the GIQLI was significantly better in the PFP group (104 vs. 84, p<0.05). Re-do fundoplication is a safe procedure and is feasible by laparoscopy. In the long-term, patient satisfaction is comparable to primary intervention with, however, a slightly poorer quality of life.